Care home resident suffered overdose after error

Thompson Elliott briefly received the wrong medication while living at Grangewood care home in Houghton-le-Spring

A man suffered an opioid overdose following confusion among care home staff over his medication.

Thompson Elliott, a resident at Grangewood in Houghton-le-Spring, was given medication in December for two days that had been stopped while he was in hospital, due to its impact on his kidneys.

The 83-year-old was successfully treated for the overdose, an inquest into his death heard, but contracted influenza and died at Sunderland Royal Hospital on 24 January.

Sunderland's senior coroner has written to provider Care UK asking it to take action. The company said changes had been made to medication processes and extra training had been provided.

Samantha Rogan, director for the North East, said: "This was a tragic incident, and we would, once again, like to express our deepest condolences to Mr Elliott's loved ones."

'Administration error'

Senior coroner David Place said new medication was not administered for two days as it had not been immediately added to Mr Elliott's electronic medication record (EMAR) and was "held in a cupboard pending clarification".

It was then incorrectly added to the record as new and additional medication instead of replacement medication.

Writing in a prevention of future deaths report, the coroner said the administration error resulted in an opioid overdose after Mr Elliott was given both his old and new medication twice on 20 December.

"I am concerned that the evidence was such that it was not possible to determine exactly what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18, 19 or 20 December, but medication continued to be administered," Mr Place said.

On 21 December, a team leader spoke to the hospital and despite being advised that if there was no discharge letter to clarify the position with the GP, a decision was made to only administer the old medication.

According to the report, there were also no attempts to contact the GP, 111 or Recovery at Home for advice.

Mr Place said the care home had no policy or guidance document setting out procedures in such circumstances, which "created confusion and inconsistent decision-making resulting in a medication overdose".

"The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death," the coroner said.

Ms Rogan said the care home would be working with local NHS partners to prioritise clearer communication around medication and hospital discharge.

"We have also made changes to our medication processes and implemented further training to ensure a similar incident is not repeated in the future," she said.

"We will continue to address the points raised and are in the process of responding to the report from HM Coroner."

A response outlining what action will be taken has to be submitted to the coroner by 11 December.